Applicant Data
Name (Last)_____________________(First)__________________(Middle)_______
Address:_____________________________________________________________
City:____________________________________ State: _____ Zip:______________
Sex: ________ Date of Birth: _______/_______/_______ Age: _______
Home Phone: (_______)_______________ Work: (________)__________________
Parent/Guardian: ______________________________________________________
____________________________________________________________________
What grade will you be attending fall 2005? __________
Check the program for which you are applying:
_____ Space Camp (Grades 4-6)
_____ Space Academy, Level 1 (Grades 7-12)
_____ Advanced Space Academy (Grades 10-12, College Bound)
_____ Aviation Challenge Mach I (Grades 4-6)
_____ Aviation Challenge Mach II (Grades 7-12)
_____ Aviation Challenge Mach III (Grades 10-12)
List any school and/or community activities in which you have participated
during the past two years (i.e. student government, music, community or school
volunteer activities). (Can be typed in print or Braille)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Why do you want to attend U. S. Space Camp/Space Academy? (Can be typed in
print or Braille)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Please answer both essay questions, limiting your answers to one typed page per question (two, if Braille)
1. What to you see as the future role of persons with visual impairments in
the space Program?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2. What benefits do you envision the Space Program giving to individuals with
disabilities?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
You will need to complete the scholarship application in its entirety and forward it along with a copy of your latest report card or transcript of grades and a letter of recommendation from your math or science teacher. Please mail all documents in one envelope to
Dan Oates
P.O. Box 1034
Romney, WV 26757
Applications must be received no later than June 1. Recipients will receive notifications on or around June 15.
Every attempt will be made to provide partial funding ($100+) to all qualified applicants. Funding amounting to 100% is rare. The Delta Gamma Foundation is responsible for funding scholarships. Our ability to provide scholarships is based on their generosity. Grant approval is announced in mid to late May.
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